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REGULATORY REVIEW


information to benchmark against other facilities, there are a couple of options.


Benchmarking programs If you participate in ASCA’s Clinical & Operational Benchmarking Survey, you will continue to collect and report on these adverse events to provide your ASC data in which to use for bench- marking. Beginning January 1, 2019, ASCA has updated its quality section of the Clinical & Operational Bench- marking Survey to include three tabs— Suspended by Medicare, Reported to Medicare and Not Reported to Medi- care—to provide your ASC with even more information about adverse events that were suspended by Medicare. For ASC-1 and ASC-2, there are nine additional “drilled down” ques- tions added to each of these questions. The “drilled down” questions will ask the area of the ASC in which the fall/ burn occurred, the impact of the fall/ burn on the patient, and the intervention taken by the ASC for the fall/burn. The facility will indicate whether


the fall/burn occurred in the preop area, intra-op area or postop area. For each of the areas, there will be an option for the facility to identify if there was no impact to the patient (interventions: no monitoring, no actions taken, no medications admin- istered, no dressing applied, etc.), minimal impact (interventions: medi- cation administered, dressing applied, etc.) or major impact (interventions: transfer to hospital for significant loss of blood, fracture, etc.). This will provide more valuable information as to the harm caused to the patient and will allow ASCs to bet- ter benchmark their facility against other facilities and determine the prog- ress made at that facility over time (to learn more about ASCA’s Clinical & Operational Benchmarking Survey, go to page 24).


Other benchmarking programs, such as those run by state associations


Even though facilities no longer have to report on patient burns (ASC-1), falls (ASC-2), wrong events (ASC-3) or hospital transfers (ASC-4) on fee-for-service (FFS) Medicare claims, it is a good idea to continue collecting this data.”


—Kara Newbury, ASCA


or other specialty organizations, might also include the collection of this data.


National Health Safety Network (NSHN)


In addition to benchmarking programs, the Centers for Disease Control and Prevention’s (CDC) NHSN portal also provides facilities with the opportunity to report on these measures through its new Outpatient Procedure Compo- nent Surveillance for Same Day Out- come Measures (OPC-SDOM) module (cdc.gov/nhsn/ambulatory-surgery/ sdom/index.html). This reporting is voluntary. If ASCs choose to partici- pate, they would fill out the Outpatient Procedure Component (OPC) Monthly Reporting Plan form (CDC 57.401). Participating facilities must indicate if they want data entered into NHSN to be used for “in-plan” or “off-plan” sur- veillance. Only in-plan data would be included in NHSN annual reports or other publications. Off-plan surveil- lance means the facility has decided to track a particular event solely for the


facility’s internal use. A plan must be completed for every month that data is entered into NHSN, although a facil- ity may choose “No NHSN Outpatient Reporting this month” as an option. In addition to the monthly report,


the ASC must complete an OPC Annual Facility Survey (CDC 57.400) which is used by CDC to “classify facilities for appropriate comparisons in aggregate data analyses and to learn more about common practices among ASCs.” Participating facilities must complete the annual facility survey at the time they enroll or activate the OPC and, subsequently, at the begin- ning of each calendar year. The OPC-SDOM surveillance proto- cols, training materials, data collection forms, instructions and other supporting materials are provided on the Outpatient Procedure Component website: cdc.gov/ nhsn/ambulatory-surgery/index.html.


Kara Newbury is ASCA’s regulatory counsel. Write her at knewbury@ascassociation.org.


ASC FOCUS APRIL 2019 | ascfocus.org 23


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